Provider Demographics
NPI:1457518722
Name:PARK, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:703-780-9014
Mailing Address - Fax:703-780-9077
Practice Address - Street 1:8101 HINSON FARM RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3403
Practice Address - Country:US
Practice Address - Phone:703-780-9014
Practice Address - Fax:703-780-9077
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251577207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457518722Medicaid
VAVV6751AMedicare PIN
VA1457518722Medicaid